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At least 559 records · Page 31Linked to original sources
PubMed1999

Shifting the paradigm in tuberculosis control: illustrations from India.

Drawing on literature from India and key contributions from social science, this paper asks and attempts to answer the question 'who is to blame for treatment failures in TB'? Some key lessons emerge: effective tuberculosis control cannot be achieved so long as the disease is considered in isolation from the social processes that maintain it, create the conditions facilitating its spread and act as barriers to care. Insights into the economic and social burdens incurred with a diagnosis of TB are essential to understand why many patients, especially the most disadvantaged, are unable to comply with treatment regimens. TB and health care interventions need to be appropriate to the health service contexts in which they are applied, and sensitive to the competing demands, needs and priorities of people's lives. The paper argues for the need to reorient TB control programmes towards enabling patients to obtain care. The problem of access emerges as central to people's ability to obtain and maintain appropriate therapy. Examples and characteristics of successful non-governmental projects, from which policy makers, programmers and practitioners could learn, are outlined and contrasted with more rigid directly observed treatment approaches. We conclude that treatment failures are not patient failures, and that TB control programmes need to address the social dimensions of TB, and adhere to the principles of good TB care, with the same commitment that is devoted to ensuring patients follow treatment guidelines. We suggest a paradigm shift away from a focus on diseased patients towards enabling health in the community.

Antitubercular Agents↗
PubMed2002

Trends in aortic valve surgery in a large multi-surgeon, multi-hospital practice, 1979-1999.

BACKGROUND AND AIM OF THE STUDY: Trends in aortic valve operations (AVO) may help to predict the future of aortic valve surgery in the context of changing case mix, population demographics, emerging technology and shifting paradigms. METHODS: All adults undergoing single AVO between 1979 and 1999 were reviewed retrospectively according to age, gender and other typical clinical variables, surgical complexity, specific operation and immediate outcome. RESULTS: There were 3,917 single AVO. Although coronary artery bypass (CAB) volumes declined by 15.3% between 1996 and 1999, AVO volumes have continued to increase by 11.7% since 1996. Over the entire period, there was no significant change in mean age or percent female gender, but increases in the prevalence of octogenarians and aortic stenosis were noted. During the 1990s, degenerative valve disease predominated and the prevalence of sicker patients according to heart failure class and surgical priority decreased. Trends in surgical complexity included an increase in AVO combined with CAB, but a stable 9:1 distribution of first operations to reoperations. Technology adoption included a decreased prevalence of mechanical valve use at the expense of increased use of tissue valves, especially stented xenografts and homografts. Transient technology adoption included stentless xenografts. Small numbers of pulmonary autografts, aortic valve repairs and valve-sparing aortic replacements were carried out. Predictors of hospital mortality rates for AVO included age 65 years, reoperation and combined AVO. Hospital mortality rates for AVO decreased for most age groups between the 1980s and 1990s, but not during the 1990s. CONCLUSION: AVO volumes are steadily increasing, apparently as a result of the increase in octogenarians and the start of the 'baby boom' wave. Hospital mortality risk is related to age and surgical complexity, but is modest and has stabilized during the past decade. The prevalence of mechanical valve implants has decreased in favor of tissue valve replacement categories. The fastest growth rates have been with stented xenografts, and especially homografts. This may represent a paradigm shift away from mechanical solutions in favor of tissue solutions for aortic valve disease.

Adult↗
PubMed2003

Trends in mitral valve surgery in a large multi-surgeon, multi-hospital practice, 1979-1999.

BACKGROUND AND AIM OF THE STUDY: Trends in mitral valve operations (MVO) may help to predict the future of mitral valve surgery in the context of changing case mix, population demographics, emerging technology and shifting paradigms. METHODS: All adults undergoing single mitral valve operations (MVO) between 1979 and 1999 were reviewed retrospectively according to age, gender and other typical clinical variables, surgical complexity, specific operation and immediate outcome. RESULTS: A total of 2,055 single MVO was performed. Although coronary artery bypass volumes declined by 15.3% from 1996 to 1999, MVO volumes have continued to increase 58.0% since 1996. For the entire period, there was an insignificant increase in mean age, but an increase in percent male gender and in the prevalence of degenerative and ischemic etiology and mitral regurgitation (MR) pathophysiology. During the 1990s, trends in surgical complexity included a stable 40% prevalence of combined MVO and a stable 9:1 distribution of first operations to reoperations. Technology adoption included a decreased prevalence of mechanical valve usage at the expense of an increased prevalence of mitral valve repair (MVRpr). The prevalence of MVRpr among individual surgeons appeared to be related to a threshold case load of 20 mitral valve operations per year. Predictors of hospital mortality rates for MVO included age > or = 65 years, reoperations and combined MVO. Age > or = 65 years was a predictor of hospital mortality for each category of overall, isolated and combined MVO, mitral valve replacement (MVR) and MVRpr except for combined MVR. Hospital mortality rates for overall MVO, first-op MVO and combined MVO decreased during the 1990s. Hospital mortality comparisons between MVR and MVRpr favored MVRpr, either significantly or by insignificant trend, in every category of overall, isolated and combined groups and when evaluated by age > or = or < 65 year, in overall, isolated and combined groups. CONCLUSION: MVO volumes are steadily increasing apparently as a result of the increase in octogenarians and the beginning of the 'baby boomer' wave. Degenerative and ischemic etiologies with MR pathophysiology are on the rise, while rheumatic and endocarditis etiologies are static. The prevalence of MVR with mechanical prostheses has decreased in favor of MVRpr. The prevalence of MVRpr among individual surgeons appears to be related to an annual threshold volume of overall MVO. Hospital mortality risk is related to age and surgical complexity, but is modest and has continued to trend down during the past decade. Hospital mortality appears to favor MVRpr over MVR in all categorical comparisons, either significantly or by insignificant trend. These opposite trend lines for MVR and MVRpr likely represent a paradigm shift away from mechanical solutions in favor of tissue solutions for mitral valve disease, especially for MVRpr.

Age Factors↗
PubMed2001

Hypertension and chronotherapy: shifting the treatment paradigm.

The treatment of diseases has been based on the concept of homeostasis and has not incorporated an understanding of biologic rhythms and their underlying mechanisms. Biologic rhythms are implicated in cardiovascular events. Failure to recognize the circadian decline in blood pressure may result in iatrogenic chronopathological events, including anterior ischemic optic neuropathy and cerebrovascular accidents. Chronotherapeutics is the purposeful alteration of drug level to match rhythms to optimize therapeutic outcomes and minimize size effects. For the treatment of hypertension, this idea has the potential for a therapeutic paradigm shift.

Blood Pressure↗
PubMed2003

Cardiac events in patients undergoing noncardiac surgery: shifting the paradigm from noninvasive risk stratification to therapy.

Internists and cardiologists are often asked to estimate the risk for perioperative myocardial infarction or cardiac death in patients being considered for noncardiac surgery. Estimating this risk in an individual patient is difficult and complex. Although noninvasive imaging tests are often used for this purpose, a review of the literature reveals that the positive predictive value of noninvasive imaging tests is uniformly low and that they do not provide information beyond that obtained by assessing simple clinical risk variables. Moreover, no evidence exists that noninvasive imaging tests lead to a therapeutic strategy that reduces the risk for perioperative myocardial infarction or cardiac death. Since the publication of guidelines for preoperative risk stratification by the American College of Cardiology/American Heart Association in 1996 and the American College of Physicians in 1997, three clinical trials have shown that beta-blocker therapy reduces the risk for perioperative cardiac events. This paper focuses on the relationship between risk stratification and subsequent therapy to minimize or eliminate risk. In short, the paradigm is shifting from predicting which patient is at high risk for having a perioperative cardiac event to minimizing the likelihood of such an event with specific perioperative pharmacologic therapy.

Algorithms↗
PubMed1995

Re-engineering of health care: opportunity or threat for occupational therapists?

The health care system is responding to a paradigm shift from the industrial era to the knowledge society. The rapidly changing administrative structures of some hospitals and increasing numbers of proposals for new models of care are disconcerting for therapists who are used to working in traditional organizational structures and models of care. However, with a broader understanding of the shift that is occurring, it becomes apparent that this paradigm shift is pushing the system toward care practices that are more consistent with occupational therapy practices than those of the traditional medical model. This paper describes the factors influencing the direction of the paradigm shift, the major emerging models of care and organizational structures associated with the paradigm shift, and then discusses the issue of whether the paradigm shift presents a threat or a challenge to occupational therapists.

Canada↗
PubMed2001

The implications of hormesis to ecotoxicology and ecological risk assessment.

Changes required for the explicit recognition of hormesis are outlined for both ecotoxicology and ecological risk assessment (ERA). A major research need is the extension of hormesis beyond chemical stressors to abiotic (e.g., habitat) and biotic stressors (e.g., species introductions, organism interactions). An overreaching research need is to determine for all stressors with model organisms, populations, and communities whether hormesis has positive, neutral, or adverse effects. The latter are the least likely; however, neutral effects cannot be ruled out. Based on our present state of knowledge, hormesis is likely to have more of an impact on ecotoxicology than on ERA. In the case of the latter, it is most likely to make a difference only in a detailed-level ecological risk assessment (DLERA), the most complex form of ERA. Further, for hormesis to be accepted fully into ecotoxicology or ERA will require a paradigm shift. Three ongoing paradigm shifts to which hormesis could be linked are: recognition of the low utility of no-observed-effects concentrations (NOECs); recognition of the need for special treatment of essential element dose concentration responses, which are similar to hormesis; and the replacement of environmental toxicology with ecological toxicology (ecotoxicology).

Adaptation, Physiological↗
PubMedDate not supplied

A low dose of ethanol impairs working memory in mice in a win-shift foraging paradigm.

Using a test of working memory which is not influenced by learning, the win-shift foraging paradigm, ethanol was found to produce amnesia in mice. This effect was produced by very low doses of ethanol, 0.5 and 1.5 g/kg, which did not alter motivation as measured by latency to leave the start box. These doses of ethanol also did not alter performance in the maze as measured by the time to traverse the maze. These data indicate that low doses of ethanol directly impair working memory--that is, the effects are not due to an alteration in learning. The win-shift foraging paradigm, which is free of some of the problems inherent in passive avoidance paradigms, may be useful in exploring the mechanism of this effect of ethanol.

Amnesia↗
PubMed2005

[Self-competence as a condition for self-determination in disabled women and girls for rehabilitation legal relations].

Self-competence is a keyword of modern reform legislation in public health and social policy in general and in disability law more specifically. The article defines self-competence from the perspective of constitutional law and describes the new provisions of Book 9 of the Social Code, SGB IX with relation to disabled women and girls. These new provisions are a response to new scientific analyses of the status of disabled women and girls. Their status is determined by multiple discrimination and by threat of sexual violence. Within this context self-competence means capacity for self-determination. Such an interpretation is in line with reforms in disability law, i. e. the adoption of anti-discrimination law. With this reform legislators pursue a shift in paradigm from the medical to the social model of disability. Such a paradigm shift demands new paths to be treaded in rehabilitation. Rehabilitation agencies have corresponding duties to protect and to promote.

Adolescent↗
PubMed1995

Total quality and the shifting management paradigm.

The concepts at the heart of total quality management (TQM) have existed for several decades, resurfacing every few years with variations, each time under a new name. Most efforts at incorporating these concepts into the operation of a business organization have failed, but each time the concepts come back, they meet with incrementally greater success than the previous time. This increasing rate of success is due largely to the shifting management paradigm. What we think and believe about management is making the gradual transition from strict authoritarianism, far more of an influence than we readily recognize, toward a practiced belief in true participative management. The closer the shifting management paradigm moves to open participation, the more success will accrue to total quality implementations.

Cost-Benefit Analysis↗
PubMed2002

Ecological risk assessment (ERA) and hormesis.

Based on our current state of knowledge, the significance and importance of hormesis is likely to be greater for ecotoxicology, a component of ecological risk assessment (ERA), than for the overall process of ERA. Appropriately determining the role of hormesis in ERA will require extension of hormesis beyond chemical stressors to abiotic (e.g. habitat) and biotic stressors (e.g. species introductions, organism interactions). It will also require determining for all stressors whether at both individual and higher levels of organization, hormesis has positive, neutral or adverse effects. This determination must be made for model organisms, populations and communities. Adverse effects are the least likely, however, neutral effects cannot be ruled out. Presently, consideration of hormetic effects in ERA is most appropriate in a detailed level ecological risk assessment (DLERA), the most complex form of ERA. It is not appropriate in either problem formulation or a screening level ERA (SLERA). Further, for hormetic effects to be recognized and accepted fully into ERA may require a paradigm shift. Three on-going paradigm shifts to which hormesis could be linked are: recognition of the low utility of no-observed effects concentrations (NOECs); recognition of the need for special treatment of essential element dose/concentration-responses, which are similar to hormetic responses; and, the replacement of environmental toxicology with ecological toxicology (ecotoxicology).

Adaptation, Physiological↗
PubMedDate not supplied

Wellness: the mode in the new paradigm.

A fundamental paradigm shift is occurring in the health care field that gives new hope to the challenge of reducing health care costs through the promotion of wellness. The authors of this paper present the present components of the new paradigm, the historical aspects of the paradigm shift, and examples of the paradigm shift in community health. The authors have also attempted to suggest ways in which individuals and communities can participate in the new paradigm.

Community Health Services↗